Senior Pi Claims Assessor

2 weeks ago

Johannesburg, Gauteng, South Africa PPS Recruitment Full time

Job Advert Summary:

This role reports to the Team Manager Claims. Responsible for assessment and management of long-term Sickness, Permanent Incapacity and Disability claims. The role will transfer specialist claims knowledge, in-depth process knowledge and client centric principles. The incumbent will deal with technical and complex claims queries and/or complaints providing an excellent service offering. A close relationship with Research & Development to support interdepartmental and wider organizational goals.

Minimum Requirements:

Education:

  • Degree in Occupational Therapy or Physiotherapy

Experience:

  • 5+ years' experience in the insurance industry.
  • 4+ years' experience in claims assessment including Income protection, Lump Sum.
  • Disability and dread disease.
  • Case Management experience is an advantage.

Knowledge and Skills:

  • Fluent in English both written and verbal.
  • Must have excellent telephone etiquette.


 Good computer knowledge
  • MS Outlook, Excel and Word are necessary.
  • Good report writing and presentation skills.
  • Must have a mature, disciplined and driven personality.
  • Ability to work independently as well as being a good teamplayer with excellent interpersonal skills.
  • Attention to detail.
  • Deadline/target driven, with ability to work under pressure.
  • Logical and analytical.
  • Effective time management skills.

Competencies:

  • Communication skills (written and verbal).
  • Business writing skills.
  • Planning and organizing.
  • Attention to detail.
  • Client centricity.
  • Building and maintaining relationships.
  • Resilience.

Duties and Responsibilities:

Process optimization and efficiencies:

  • Assessment and management of longterm Sickness, Permanent Incapacity and Disability claims.
  • Check the technical aspects of the claim
  • Inclusive of potential nondisclosure, and exclusions.
  • Review all medical information on file, analyze and synopsize information at hand.
  • Determine and record additional required information.
  • Decide on referral to an independent specialist.
  • Receive Independent Specialist reports and analyze and synopsize the report in context of the claim and PPS Provider Policy.
  • Present the claims at Medical Officers Committee for assessment.
Prepare detailed referral letters to independent specialists and detailed decision letters to members.

  • Manage longterm claims by facilitating potential rehabilitation and return to work programs with appointed specialists.
  • Correspondence to clients with respect to claims outcomes and requirements for future claims in order to manage claims.
  • Conduct member visits or member meetings when required.
  • Keeping accurate records of all claims assessed in accordance with departmental procedures.
  • Deal with Arbitration and Ombudsman cases and collaborate with other stakeholder during the Complaints process.
  • Participation in projects to improve departmental serviceowning your role in the project and completing tasks as required by providing input.

Risk and Compliance:

  • Adhere to internal SLA's to ensure operational efficiency and achievement of agreed customer service standards.
  • Proficient in the assessment and management of claims.
  • Must understand claims environment and general claims protocols and processes.
  • Ensure adherence to audit requirements.
  • Ensure adherence to regulatory and compliance requirements.

People and Culture:

  • Checking and Authorization of claims in terms of published delegation of authority.
  • Collaboration with relevant stakeholders: Research & Development, Legal, Operational Accounts, Nondisclosure and Internal Control.
  • Contribute and assist to review processes and protocols where required to assist in PPS' delivery of quality claims decisions.
  • Forge strong working relationships with stakeholders.

Knowledge Champion:

  • Empower team members with transfer of knowledge, be the Operations Team SME.
  • Ensure that own knowledge is kept abreast with industry & regulatory information and changes through various internal and external information sources.
  • Provide technical information and support.

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